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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 42-44

A rare case of re-expansion pulmonary oedema after medical thoracoscopy


1 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of General Medicine, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission05-Jan-2019
Date of Decision04-Nov-2019
Date of Acceptance21-Nov-2019
Date of Web Publication2-Jun-2020

Correspondence Address:
Deependra Kumar Rai
Associate Professor and Head, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_5_19

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  Abstract 


Re-expansion pulmonary oedema of the lung occurs after rapid removal of air or liquid from the pleural space by either chest drainage or thoracocentesis. Re-expansion pulmonary oedema is a rare but serious complication. A 29-year-old male patient presented to us with left-sided massive pleural effusion. We performed medical thoracoscopy; however, an hour after procedure, he started having cough and increased breathlessness. Chest radiograph showed left-sided homogeneous opacity in the left mid and lower zone consistent with unilateral pulmonary oedema. He was managed conservatively along with bi-level positive airway pressure non-invasive ventilator support. His condition improved gradually and was discharged successfully after 5 days.

Keywords: Medical thoracoscopy, pleural effusion, re-expansion pulmonary oedema


How to cite this article:
Rai DK, Karmakar S, Thakur S, Kirti R. A rare case of re-expansion pulmonary oedema after medical thoracoscopy. J Clin Sci Res 2020;9:42-4

How to cite this URL:
Rai DK, Karmakar S, Thakur S, Kirti R. A rare case of re-expansion pulmonary oedema after medical thoracoscopy. J Clin Sci Res [serial online] 2020 [cited 2020 Aug 15];9:42-4. Available from: http://www.jcsr.co.in/text.asp?2020/9/1/42/285714




  Introduction Top


Re-expansion pulmonary oedema is a rare and often fatal complication following re-expansion of the lung after rapid removal of air or fluid from the pleural space by either thoracocentesis or chest drainage. The reported incidence following drainage of pleural effusion and pneumothorax has been variable.[1] Risk factors for re-expansion pulmonary oedema are not known, and prevention strategy such as limiting the pleural fluid aspiration to 1 litre over 24 h may be safe strategy.[2] Thoracoscopy procedure is generally performed with drainage of all pleural fluid and allows lung to collapse for complete visualisation of the pleura anatomy before lung re-expansion. Our case report describes post-procedure development of re-expansion pulmonary oedema after medical thoracoscopy. Occurrence of this complication after thoracoscopy is rarely described in literature.


  Case Report Top


A 29-year-old male presented with shortness of breath, dry cough, abdominal fullness and constipation for the last 1½ months. He was a non-smoker and gave a past history of alcohol consumption. He had been receiving anti-tuberculosis treatment for the past 1 month from a local practitioner. His pulse was 122/min, blood pressure (BP) 120/92 mm Hg, respirations 28/min, and oxygen saturation measured by pulse-oximetry (SpO2) 94% while breathing room air. Chest examination and chest radiograph [Figure 1]a revealed left-sided massive pleural effusion with mediastinal widening. Contrast-enhanced computed tomography (CECT) thorax showed a large lymph nodal mass in the mediastinum with discrete lymph nodes in the upper abdomen and mediastinum. Homogeneous contrast enhancement with adjacent mediastinal pleural infiltration and vascular encasement by the nodal mass was also evident. Multifocal nodular pleural thickening with gross pleural effusion and complete collapse of the left lung was seen [Figure 1]b. Haemogram, liver function tests, renal function tests, and serum electrolytes were within normal limits. Diagnostic thoracentesis and Pleural fluid analysis revealed lymphocytic exudates. Pleural fluid adenosine deaminase levels were elevated (54 IU/L). Pleural fluid smear was negative for acid-fast bacilli and malignant cytology. Differential diagnosis included tuberculosis, lymphoma, and germ cell tumour. We performed a medical thoracoscopy on the patient with a semi-rigid thoracoscope and intermittently, approximately 1500 mL pleural fluid was aspirated by suction for adequate visualisation of the thoracic cavity and pleural surfaces. The parietal pleura showed nodular deposits from which a biopsy was obtained. An intercostal chest drain (ICD) was placed and clamped, and the patient was sent to ward. The patient vitals during the procedure were pulse 102/min, respirations 22/min, BP 114/88 mm Hg, and SpO2 98% while breathing oxygen at 2 L/min. One hour later, the patient complained of progressively increase in breathlessness and paroxysms of dry cough; pulse was 128/min, respirations 32/min, BP 92/40 mm Hg, and SpO2 was 88% while breathing oxygen at 8 L/min. On auscultation, air entry was reduced on the left side of chest and fine crepitations were heard. Arterial blood gas analysis while breathing oxygen at 8 L/min showed pH 7.42, arterial oxygen tension (PaO2) 59 mm Hg, arterial carbon dioxide tension (PaCO2) 27.5 mm Hg, arterial oxygen saturation (SaO2) 89%, and bicarbonate (HCO3) 18.3 mEq/L. We considered differentials such as bleeding inside pleural cavity, left ventricular failure or re-expansion pulmonary oedema. In view of criticality of patient condition, we shifted the patient to intensive care unit where he was started on non-invasive ventilation (NIV) with bi-level positive airway pressure (BiPAP) at 12 inspiratory positive airway pressure and 5 expiratory positive airway pressure with oxygen at FiO2 40%, titrated to SpO2 of 95%. The respirations were stabilised to 24/min after 4 h. Bedside chest X-ray showed heterogeneous opacity in the left mid and lower zone with ICD in situ [Figure 2]a. We made a diagnosis of post-thoracoscopy re-expansion pulmonary oedema. On the next day, the patient was stable with pulse 92/min, BP 112/73 mm Hg, RR 22/min, and SpO2 97% at 1 L O2/min. Chest radiograph beside revealed marked resolution of left-sided homogenous opacity with minimal pleural effusion and ICD in situ [Figure 2]b. We ensured ICD output of <1000 mL over 24 h. On post-procedure day 3, the patient had a SpO2 of 97% on room air. On post-procedure day 5, ICD output reduced to less than 100 ml in 24 h. ICD was removed and purse-string suture applied. The histopathology of pleural biopsy was reported as non-Hodgkin's lymphoma, and the patient was referred to the Medical Oncology Department for further management.
Figure 1: Chest X-ray (postero-anterior view) before thoracoscopy showing left-sided pleural effusion with mediastinal widening (a). Computed tomography chest showing nodal mass (b)

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Figure 2: Chest X-ray showing resolution of opacity present in left hemithorax. Chest X-ray (anteroposterior view) after procedure showing heterogeneous opacity in the left mid- and lower-zone with intercostal tube in situ (a). Chest X-ray showing resolution of the lesion (b)

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  Discussion Top


Re-expansion pulmonary oedema is a rare but serious complication of draining pleural effusions or pneumothoraces; it is reported to occur in <1% of cases, but mortality can be high as 20%.[3],[4] Usually, there is underreporting as many cases are mild and can be solely diagnosed on chest radiography.[3] re-expansion pulmonary oedema usually presented with dyspnoea, coughing and chest discomfort, which starts within 24 h and 64% of patients having onset within 1–2 h after lung re-expansion.[3] The risk factors are age between 20 and 40 years, female gender, duration of collapse greater than 72 h, application of high negative pressures during thoracic drainage (>20 cm H2O) and rapid lung expansion with drainage of large volumes of pleural fluid (>1.5 L).[3],[4],[5] In our case, the patient developed re-expansion pulmonary oedema 1 h after thoracoscopy and responsible factor could be large amount of pleural fluid inadvertently drained to get a better thoracoscopic view of the pleura. The exact pathophysiology of re-expansion pulmonary oedema is not defined and proposed mechanisms include excess negative pleural pressure causing mechanical stress, hypoxic damage to the chronically atelectatic lung, increased alveolar-capillary permeability and reperfusion injury.[4] There are several case reports of occurrence of re-expansion pulmonary oedema after chest tube insertion for pneumothorax,[6] pleural effusion.[7],[8],[9] There are also case reports of re-expansion pulmonary oedema following video-assisted thoracoscopic surgery.[10] The treatment is generally conservative but varies depending upon severity. Treatment is started with oxygen inhalation to positive pressure ventilation. The use of NIV may eliminate the need of mechanical ventilation. There is doubtful role of diuretics, bronchodilator and steroids. Most of the patients recover within 5–7 days. In our case, we treated the patient with BiPAP and oxygen inhalation, and he completely recovered in 2 days.

We report this case as this report documents the uncommon occurrence of re-expansion pulmonary oedema following medical thoracoscopy. Given the frequent use of medical thoracoscopy, this case provides awareness of a rare but significant complication that requires rapid recognition and treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Echevarria C, Twomey D, Dunning J, Chanda B. Does re-expansion pulmonary oedema exist? Interact Cardiovasc Thorac Surg 2008;7:485-9.  Back to cited text no. 1
    
2.
Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007;84:1656-61.  Back to cited text no. 2
    
3.
Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg 1988;45:340-5.  Back to cited text no. 3
    
4.
Neustein SM. Reexpansion pulmonary edema. J Cardiothorac Vasc Anesth 2007;21:887-91.  Back to cited text no. 4
    
5.
Matsuura Y, Nomimura T, Murakami H, Matsushima T, Kakehashi M, Kajihara H. Clinical analysis of reexpansion pulmonary edema. Chest 1991;100:1562-6.  Back to cited text no. 5
    
6.
Chakraborty PP, Chakraborty S. Reexpansion pulmonary edema. Indian J Surg 2012;74:174-6.  Back to cited text no. 6
    
7.
Dias OM, Teixeira LR, Vargas FS. Reexpansion pulmonary edema after therapeutic thoracentesis. Clinics (Sao Paulo) 2010;65:1387-9.  Back to cited text no. 7
    
8.
Maitra S, Mutheriyil N, Patnaik R, Bhattacharjee S. Reexpansion pulmonary edema after hepatic hydatid cyst excision. J Clin Anesth 2016;34:310-1.  Back to cited text no. 8
    
9.
Petiot A, Tawk S, Ghaye B. Re-expansion pulmonary oedema. Lancet 2018;392:507.  Back to cited text no. 9
    
10.
Yim AP, Liu HP. Complications and failures of video-assisted thoracic surgery: Experience from two centers in Asia. Ann Thorac Surg 1996;61:538-41.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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